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  1. psnet.ahrq.gov/web-mm/failure-rescue-mother
    September 23, 2020 - Failure to Rescue the Mother Citation Text: Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865778/psn-pdf
    May 29, 2024 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement May 29, 2024 Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-complications-unint…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33806/psn-pdf
    April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH April 1, 2016 In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics a…
  4. www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide5.html
    October 01, 2022 - Preventing Hospital-Associated Venous Thromboembolism Chapter 5. Implement the VTE Prevention Protocol Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care De…
  5. psnet.ahrq.gov/perspective/conversation-withsorrel-king
    March 01, 2007 - In Conversation with...Sorrel King March 1, 2007  Also Read an Essay Citation Text: In Conversation with..Sorrel King. PSNet [internet]. 2007.In Conversation with...Sorrel King. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33637/psn-pdf
    August 01, 2006 - In Conversation with...Lucian Leape, MD August 1, 2006 In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withlucian-leape-md Dr. Robert Wachter, Editor, AHRQ WebM&M: What kind of career did you fashion for yourself prior to getting involved in safety an…
  7. psnet.ahrq.gov/web-mm/undetected-foreign-object
    April 24, 2018 - Undetected Foreign Object Citation Text: Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
  8. psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
    January 29, 2020 - Delayed Recognition of a Positive Blood Culture Citation Text: Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…
  9. www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
    January 01, 2024 - Final Progress Report: How Do Consumers View the Risks of Medical Errors? FINAL REPORT Title of Project: How Do Consumers View the Risks of Medical Errors? Principal Investigator: Ellen Peters Team Member: Paul Slovic Organization: Decision Research Inclusive Dates of Project: 09/01/2001 – 08/31/2003 Federal …
  10. psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
    February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency Citation Text: Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…
  11. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
    June 03, 2008 - Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement Jamie N. Deis, MD; Keegan M. Smith, MD; Michael D. Warren, MD; Patricia G. Throop, BSN, CPHQ; Gerald B. Hickson, MD; …
  12. www.ahrq.gov/sites/default/files/2025-03/newman-toker-report.pdf
    January 01, 2025 - Final Progress Report: A Multiyear Grant To Support the Diagnostic Error in Medicine (DEM) Annual Conference FINAL PROGRESS REPORT TITLE PAGE (R13HS019252, PI Newman-Toker) Title: A Multiyear Grant to Support the Diagnostic Error in Medicine (DEM) Annual Conference Principal Investigator: David E. Newman-Toker Tea…
  13. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
    January 01, 2025 - Table of Contents: Volume 1. Assessment Contents Volume 1. Assessment Prologue: Laying the Foundation Kerm Henriksen Looking Forward, Benefiting from the Past Envisioning Patient Safety in the Year 2025: Eight Perspectives Kerm Henriksen, Caitlin Oppenheimer, Lucian Leape, et al. What Exactly Is Patien…
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
    June 02, 2025 - Pressure Ulcer Prevention Toolkit Pressure Ulcer Prevention Toolkit Module 3 Tools 3A: Pressure Ulcer Prevention Pathway for Acute Care 3B: Elements of a Comprehensive Skin Assessment 3C: Pressure Ulcer Identification Notepad 3D: The Braden Scale for Predicting Pressure Sore Risk 3E: Norton Scale 3F: Care Plan 3G: Pat…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848109/psn-pdf
    April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride Extravasation. April 26, 2023 The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation The Case A 52-year-old man with a history of lymphoplasmacytic lymph…
  16. www.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
    December 01, 2012 - Facilitator Notes CUSP Toolkit, Apply CUSP The Apply CUSP module of the CUSP Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes towards risk. This module also summarizes the concepts and activities of the other six modules in the CUSP Toolkit, including TeamSTEPPS®…
  17. www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-obhemorrhage.html
    July 01, 2023 - Labor and Delivery Unit Safety: Obstetric Hemorrhage AHRQ Safety Program for Perinatal Care Purpose of the tool: This tool describes the key perinatal safety elements related to the management obstetric hemorrhage. The key elements are presented within the framework of the Comprehensive Unit-base…
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/TableofContents_Vol4.pdf
    January 01, 2025 - Table of Contents: Volume 4. Technology and Medication Safety Contents Volume 4. Technology and Medication Safety Prologue: Technology and Medication Safety Mary L. Grady Health Information Technology “Safeware”: Safety-Critical Computing and Health Care Information Technology Robert L. Wears, Nancy G. Lev…
  19. www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/social-needs-tool.pdf
    May 01, 2021 - IDENTIFYING AND ADDRESSING SOCIAL NEEDS IN PRIMARY CARE SETTINGS NATIONAL CENTER FOR EXCELLENCE IN PRIMARY CARE RESEARCH 1 IDENTIFYING AND ADDRESSING SOCIAL NEEDS IN PRIMARY CARE SETTINGS Should our primary care practice screen for social needs? Social determinants of health (SDOH) are widely r…
  20. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-facilitator-guide.docx
    June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use 1 Improving Antibiotic Use Is a Patient Safety Issue Long-Term Care Slide Title and Commentary Slide Number and Slide Improving Antibiotic Use Is a Patient Safety Issue Long-Term Care SAY: Welcome to this presentation titled “Improving Antibiotic Use Is a Patie…